8 November 2010

Dangers of sepsis magnified in elderly

ALL efforts should be made to prevent delirium in patients with sepsis based on new research showing a significant increase in physical and cognitive dysfunction after the infection, an Australian geriatrician has recommended.

Associate Professor Michael Woodward, director of aged care and residential care services at Austin Health, Melbourne, said most of the cognitive and possibly some of the functional impairments after sepsis might simply be due to sepsis-induced delirium, which was increasingly recognised as damaging the brain.

“In other words, sepsis may be better tolerated if no delirium results and the emphasis should be on delirium prevention in unwell, older people,” he said.

Professor Woodward was commenting on a study in JAMA which found severe sepsis was associated with a tripling in the odds of long-term moderate to severe cognitive impairment, from 6.1% before sepsis to 16.7% afterwards.(1)

Further, severe sepsis was associated with the development of about 1.5 new functional limitations in patients with moderate, mild or no pre-existing functional limitations.

These new disabilities were substantially larger than those following non-sepsis general hospital admissions and persisted for at least 8 years.

“An episode of severe sepsis, even when survived, may represent a sentinel event in the lives of patients and their families, resulting in new and often persistent disability, in some cases even resembling dementia,” the authors said.

“If causally related, this represents a substantial public health burden of accelerated or de novo brain dysfunction, and one that has received almost no attention, even in the face of the dramatically increasing incidence of severe sepsis.”

The researchers said the new deficits in cognition and function likely resulted in a pivotal downturn in patients’ ability to live independently.

The study involved a prospective cohort of 1194 patients who had 1520 hospitalisations for severe sepsis drawn from the Health and Retirement Study, a long-running study of more than 27 000 older Americans.

The cohort was drawn from a group of 9223 study respondents who had a baseline cognitive and functional assessment and Medicare claims. Within this group, data from 516 patients who had survived severe sepsis were compared with data from 4517 patients who had survived a non-sepsis hospitalisation.

Professor Woodward said sepsis was a significant problem in Australia.

Extrapolating from the US study, there could be 1600 new cases of moderate or severe cognitive impairment after sepsis every year in Australia and the problem was likely to increase because of the ageing population, he said.

Extra caregiver time, nursing home admission, depression and deaths would all impact on the public health system and incur considerable cost.

“Clearly we need to prevent sepsis where possible, recognise it early and aggressively manage it,” Professor Woodward said.

Preventive measures could include vaccination against pneumococcus, controlling diabetes well and seeking help to heal leg ulcers.

Dr Roger Clarnette, consultant physician in geriatric medicine at Fremantle Hospital in WA, said other preventive measures could include keeping all immunisation, including flu shots, up to date and sticking to a rigorous exercise program.

“Lots of exercise in middle age does protect brain function and preserves muscle bulk and one of the core findings of this study was that functional decline related to loss of muscle bulk,” he said.

An editorial in JAMA said information in the study could help physicians when assessing care options and discussing outcomes with patients and families.(2)